Group cognitive-behavioural therapy

1. Introduction

Version followed: the San Francisco General Hospital (SFGH)/UCSF Group Cognitive Behavioral Therapy for Depression leader guidebooks, August 2006 revision (Miranda, Woo, Lagomasino, Hepner, Wiseman & Muñoz; revising the 2000 manuals by Muñoz, Ghosh Ippen, Rao, Le & Dwyer), three 4-session modules (Thoughts, Activities, People Interactions). Heimberg & Becker's (2002) CBGT for social phobia is used as the reference closed-group, exposure-based format, but only its published chapter structure is drawn on. [source: SFGH Leader's Introduction; Guilford CBGT contents page]

Group CBT is a delivery format, not a single therapy: a CBT protocol for a given problem (depression, social anxiety, other anxiety disorders, substance use, psychosis, PTSD, inpatient care and more) delivered to several clients at once by one or two leaders. Bieling, McCabe & Antony (2022) frame their textbook against the assumption that a CBT group is just individual CBT done in a room together; their position is that group process should be used deliberately to improve outcomes. [source: Guilford page for Bieling et al. 2022 (description only; book not drawn on)]

Change model in the version followed: an upsetting event (job loss, illness) can start a downward spiral in which harmful thoughts, fewer healthy activities and fewer or more negative contacts with people deepen low mood. Each of the three links can be worked from the other direction to lift mood. The manual says plainly that the person did not cause their depression and should not be blamed for it. The group adds support, peer modelling and practice with other people. [source: SFGH Thoughts, Activities and People guidebooks, Session 1 of each]

2. Framework

A. SFGH rolling-module group (version followed) [source: SFGH Leader's Introduction; module guidebooks]

Structure: three independent modules (Thoughts and Your Mood; Activities and Your Mood; People Interactions and Your Mood), four sessions each, 12 sessions in total. [uncertain] The Palo Alto University i4health page describes the 2000 manuals as four modules (thoughts, activities, people, health) and 16 sessions, and the 2006 Introduction mentions a fourth module on substance use that is not described. This guide follows the 2006 three-module guidebooks.
Enrolment: open or rolling. New members join only at Session 1 of a module. A member who has finished every module graduates.
Format: 1.5 to 2 hours per session, about 8 to 10 members, two co-leaders recommended. A leader change should fall at the first session of a module, with about four weeks' notice, and the two leaders should never leave at the same time.
Fixed session agenda (every session): welcome and announcements → review (mood and practice) → new topic → key messages → practice assignment → feedback → looking ahead. Practice is also checked informally as members arrive. Timings sit in each session's "Leader Tips" boxes.
Measures: PHQ-9 at Sessions 1 and 3 of each module, scanned in session for suicidal ideation. Members rate mood daily on the 1–9 Quick Mood Scale, which picks up extra items as the module goes on (harmful thoughts noticed, activity counts, positive and negative contacts).
Session 1 of every module repeats the entry material (rules, introductions, depression education, CBT model) so it works as a door for new members.
Criteria for moving on and stepping up:
- A member moves forward by attending through a module. There is no mastery test, and the manual says nobody is expected to learn everything the first time.
- If a member has not improved after about four sessions (persistently low or worsening Quick Mood Scale ratings, or other symptoms), the leader consults the supervisor.
- Suicidal or violent thoughts, or harm to or by the member, go to the supervisor at once, before the session ends.
- Bipolar disorder not being treated with medication, and psychosis, make a person a poor candidate. The supervisor decides on inclusion.
- Graduation: an individual meeting of about 30 minutes, roughly two weeks before the last session, then a group goodbye.
Leader requirements: training in assessing and treating mood disorders, mental-health coursework, a grasp of CBT principles, supervision by a licensed psychiatrist, psychologist or LCSW with CBT and depression experience, and observing or co-leading with the supervisor before running a group alone. No formal certification, licence or fidelity rating system is described. A leader self-evaluation form follows each session. The manuals are distributed free by Palo Alto University's i4health site. [source: SFGH Introduction; i4health Group CBT page]

B. Closed, exposure-based protocol group (CBGT for social phobia, Heimberg & Becker 2002) [source: Guilford CBGT page and contents]

Published sequence: assessment → an individual treatment orientation interview before the group starts → Session 1 → Session 2 → Sessions 3–12, built around in-session exposures combined with cognitive restructuring, plus homework procedures and troubleshooting. The manual has 12 sessions.
[uncertain] Session length, group size, the number of therapists and the exact contents of Sessions 1–2 are not drawn on here. Check them in the manual before delivering CBGT under its name. No certification requirement was found.

C. Choosing a format [synthesis]

Rolling modules: suit services with constant intake, such as depression clinics and primary care.
Closed cohorts: suit protocols that build session on session (exposure hierarchies, CBGT) and depend on cohesion for exposure work.
Before running any group: decide inclusion and exclusion criteria, the maximum size, the co-leader pairing and the supervisor's crisis pathway.

3. Guiding principles

[source: SFGH Leader's Introduction and module guidebooks unless tagged]

Collaborative, warm and structured: keep to the agenda, but teach through discussion, members' own examples and group problem-solving, not lecture.
Present-focused and practical: tell members at the start that they will not lie on a couch or talk about childhood at length, and steer back to current thoughts, activities and contacts.
No blame: say clearly and often that negative thoughts or behaviour did not cause the depression. Point out self-blame as it appears.
Practice is the active ingredient: review practice in every session. Missed practice is something to solve with the member, not a reason for criticism.
Credit belongs to the member: have members credit their own effort for improvement, not the leader or the group.
Repetition is normal: nobody needs to learn everything the first time. Repeating a module is legitimate.
Not just positive thinking, not a cure-all: correct both expectations. Treat "CBT should fix everything" as all-or-nothing thinking.
Helpful and harmful are labels for a thought's effect: a thought is judged by its effect on mood and behaviour, not by whether it is pleasant.
Everyone speaks every session: manage airtime actively.
Confidentiality and its limits: state them, including mandatory reporting, in Session 1 of every module.
No socialising outside the group, and no relatives, friends or colleagues in the same group: this protects confidentiality, keeps sharing open and prevents cliques. Watch for guarded participation when members already know each other.
Coming late or without practice beats staying away: say this explicitly.
Veterans teach newcomers: invite returning members to explain routines and share their experience. Teaching consolidates their own learning.
Leaders don't handle risk alone: suicidal or violent thoughts and abuse go to the supervisor within the session.
Use group process on purpose: a CBT group is not individual therapy with an audience. Use members' interactions, feedback and modelling as part of the treatment. [source: Bieling et al. 2022 publisher description]
Universality and hope: point out common experiences across members ("several of you described the same thought") to reduce shame, and use members who are improving as credible models. [synthesis]
Every point back to the group: after individual work, ask what the others took from it, so that each piece of work is used by everyone. [synthesis]

4. Intervention inventory

Unless tagged otherwise, all entries come from the SFGH 2006 leader guidebooks, paraphrased. Worksheets, the PHQ-9 and the thought and activity lists are not reproduced. Use the free originals. Example language is the guide's own wording unless quoted. Some entries come from parts of the guidebooks that are known from contents only (Thoughts Sessions 3–4, the end of Activities Session 3 and Session 4, People Sessions 3–4). They are named from each guidebook's contents and tagged [uncertain].

A. Group-level procedures

4.1 Pre-group orientation contact

Purpose / when: before a new member's first session, to prepare them and spot concerns.
Steps:
1. Phone or meet the person.
2. Explain the group's purpose, logistics, the leaders and how to contact them.
3. Ask about the referral, main concerns, previous treatment, goals and reservations.
4. Agree which module they will start with.
5. If they miss Session 1 of a module, offer a catch-up, for example 30 minutes before Session 2.
Example language (illustrative): "Before you come, I'd like to hear what you hope to get from the group and anything that makes you hesitant about it."
Watch for: exclusion flags (untreated bipolar disorder, psychosis) to take to the supervisor; worries about meeting people they know.

4.2 Group rules and confidentiality (Session 1 of every module)

Purpose / when: to set a safe frame, every time new members join.
Steps: go through attendance; confidentiality and its exceptions, including mandatory reporting; respect; balancing talking and listening; practice between sessions; no socialising outside the group. Ask for agreement and questions.
Example language (illustrative): "What's said here stays here, with a few legal exceptions I'll spell out now, so nobody is surprised later."
Watch for: members who already know each other; misunderstandings about the exceptions.

4.3 Introductions that are not about depression

Purpose: to present members as whole people and build connection.
Steps:
1. Each member gives their name and one or two things such as hobbies, work or where they grew up.
2. Gently redirect anyone who describes only their depression.
Example language (illustrative): "We'll get to the depression soon. For now, tell us something you enjoy or used to enjoy."

4.4 Depression psychoeducation with board brainstorm

Purpose: to normalise symptoms and introduce the model.
Steps:
1. Ask members to name symptoms they have noticed and write them on the board.
2. Map them onto the nine symptoms, including the threshold of five or more symptoms for two weeks.
3. Discuss common triggers and "what you can do".
Watch for: suicidal ideation mentioned in the room. Acknowledge it, contain it, and speak to the person and the supervisor before they leave.

4.5 CBT model and downward spiral

Purpose: to give the shared map the whole course uses.
Steps:
1. Draw a triangle of thoughts, behaviour (activities) and people interactions around mood, with two-way arrows.
2. Draw the spiral down from an upsetting event.
3. Show that each link can also be worked upward.
4. Repeat that this is not about blame.
Example language (illustrative): "Depression often pulls on all three at once. In this group we learn to push back on each one."

4.6 Quick Mood Scale with volunteer graph

Purpose: daily self-monitoring that makes links visible.
Steps:
1. Members rate mood 1–9 each day.
2. Later in the module, they add counts (harmful thoughts noticed, healthy activities, positive and negative contacts).
3. In review, graph one volunteer's week on the board and ask the group what patterns they see.
Watch for: sustained low or falling ratings after about four sessions, which call for a supervisor consult.

4.7 PHQ-9 monitoring

Purpose: to track outcome and screen risk.
Steps:
1. Members complete it at Sessions 1 and 3 of each module.
2. Leaders scan it during the session for big changes and for the suicidal-ideation item.
3. If that item is endorsed, consult the supervisor the same day.
(A licensed instrument. Use the official form.)

4.8 Mood rating before and after the session

Purpose: to show members that their own effort, such as coming to the group, can shift mood.
Steps: members rate mood at the start and the end of the session, then compare.
Watch for: a member who feels worse afterwards. Respond warmly and ask what about the group did not fit.

4.9 Veteran–newcomer integration

Purpose: to absorb new members and consolidate learning for veterans.
Steps:
1. Name the change in membership aloud.
2. Ask veterans to describe what the group has been like and to explain routines such as the mood scale and practice review.
3. Let non-graduating members talk about losing graduates.
Example language (illustrative): "Maria, could you show our new members how you've been using the mood scale?"

4.10 Graduation meeting and group goodbye

Purpose: consolidation and relapse prevention.
Steps:
1. About two weeks before the last session, meet the member individually for about 30 minutes.
2. Review their mood trajectory, credit their effort, name the skills that helped, and plan relapse prevention and next steps.
3. Make time in the last session for goodbyes.

B. Thoughts and Your Mood module

4.11 Thought–mood cartoon

Purpose: to show that the same event produces different moods depending on the thought about it (Session 1).
Steps:
1. Show one event, the cartoon's example being rain, with different thoughts about it.
2. Ask the group what mood each thought would lead to.
3. Define thoughts as sentences we tell ourselves.
Example language (illustrative): "Same rain, two people, two different sentences in their heads. What does each sentence do to their mood?"

4.12 Recalling a recent low moment

Purpose: to catch real harmful thoughts.
Steps:
1. Members close their eyes and recall a recent time their mood dropped.
2. They open their eyes and write down the thoughts they had.
3. Examine the thoughts with the group using the guidebook's two questions.
4. Compare them with the guidebook's example lists of harmful and helpful thoughts, and add their own.
Watch for: members drawn into rumination. Keep the recall brief and move straight to writing.

4.13 Thought cards

Purpose: daily practice in noticing thoughts (from Session 1 on).
Steps:
1. On an index card, members write 4–5 harmful thoughts on the minus side and 4–5 helpful thoughts on the plus side.
2. Each day they notice and count thoughts, aiming at 5–10 helpful thoughts a day.
3. In Session 2 they add labels for thinking habits.
Working if: cards come back with the member's own wording, not copied examples.

4.14 Chaining (thoughts version)

Purpose: to show that mood follows a chain of thoughts that can be steered (Session 2).
Steps:
1. Draw a 1–9 scale and put a neutral fact at 5. The manual's example is losing a job.
2. The group builds a chain of thoughts that moves mood down to 1, then a chain that moves it up to 9.
3. Members complete their own chain on a worksheet.
Example language (illustrative): "The fact stays at 5. What's the next thought that drags it to 4? And what thought could lift it to 6?"
Watch for: helpful chains that are just positive thinking. Keep them accurate.

4.15 Accurate, complete, balanced test

Purpose: a three-question check on any thought.
Steps:
1. Ask whether the thought is accurate, whether it is complete (leaving nothing important out), and whether it is balanced.
2. Reword it to pass all three.
Example language (illustrative): "'I'm a failure.' Is it accurate? Complete? Balanced? What wording would pass all three?"

4.16 Labelling the eleven thinking habits

Purpose: to recognise patterns (Session 2).
The eleven habits: all-or-nothing thinking, pessimism, negative filter, exaggerating, labelling, not giving oneself credit, blaming oneself, overgeneralisation, "should"-ing, mind reading, negative fortune telling. Each comes with guiding questions.
Steps:
1. Teach a few habits at a time.
2. Members sort their own thought-card items into the habits.
3. Ask others in the group whether they recognise the same habit.
Watch for: members labelling themselves for having habits, which is itself labelling. Point it out lightly.

4.17 Talking back to harmful thoughts [uncertain: Session 3 body]

Purpose: to change thoughts once they have been caught.
Named strategies: examine the evidence; find a replacement thought; "Catch It, Check It, Change It".
Steps (paraphrased from the session outline; the detailed steps are [synthesis]):
1. Take a thought from a member's card.
2. The group lists evidence for and against it on the board.
3. The member writes a replacement thought.
4. The member re-rates how much they believe each thought.
Example language (illustrative): "Let's be detectives as a group. What's the evidence for this thought, and what doesn't fit it?"
Watch for: group members arguing a member out of a thought. The member chooses the replacement.

4.18 More helpful thoughts: "yes, but" balancing and worry time [uncertain: Session 4 named from contents only]

Purpose: to increase helpful thoughts and contain worry.
Steps ([synthesis] around the named items):
1. Members add a balancing "yes, but…" to a harmful thought.
2. They set a fixed daily worry period and postpone worries to it.
3. Review the module, say goodbye to graduates and preview the Activities module.

C. Activities and Your Mood module

4.19 Barrier checklist and one formerly enjoyed activity

Purpose: to name how depression blocks activity, and how inactivity deepens depression (Session 1).
Steps:
1. Discuss the two-way link between activity and mood.
2. Members tick the common barriers that apply to them on a checklist.
3. Each member names one activity they used to enjoy and does it before the next session.

4.20 Chaining (activities version)

Purpose: to show how mood follows what we do (Session 2).
Steps:
1. Put a real event at 5 on the 1–9 scale. The manual uses a bowling-league example.
2. The group lists activities, or avoidance, that would move mood down to 1 and up to 9.
3. Members chart their own chain.

4.21 Getting past "not feeling like it"

Purpose: to separate acting from feeling (Session 2).
Steps:
1. Members complete sentence stems about what happens if they act and what happens if they don't.
2. Introduce acting "as if" and taking small steps.
Example language (illustrative): "Waiting until you feel like it can mean waiting a long time. What's the smallest piece you could do anyway?"

4.22 Generating activities: prompts, four categories, idea list

Purpose: to build a personal menu of activities (Session 2).
Steps:
1. Prompt members with questions about past plans, childhood dreams and what others enjoy.
2. Sort ideas by alone or with others, free or low cost, and quick or simple.
3. Place ideas into four categories: self-care, fun, learning, meaningful.
4. Review the manual's list of healthy activities and add the group's own.
Watch for: ideas that don't fit members' money, health or caregiving situation. The Leader Tips include adaptations, for example for mothers and for people with physical illness.

4.23 Signed activity commitment

Purpose: to raise follow-through (Session 2).
Steps:
1. Each member picks one activity: solo or social, free or low cost, and quick.
2. They sign a commitment to do it before the next session.
3. Review it at the start of the next session.

4.24 Five-step problem solving for obstacles

Purpose: to get around practical barriers (Session 3).
Steps:
1. Name the obstacle, using a "detective" worksheet and its "I would have done it, but…" prompt.
2. The group brainstorms solutions without judging them.
3. The member chooses one or two.
4. The member tries them.
5. If they don't work, try another.
A table in the manual covers ten common obstacles, such as no time, no money, low energy and pain.
Example language (illustrative): "Let's hear every idea first, even odd ones. Then Sam picks what might work."
Working if: the member, not the group, chooses the solution, and reports trying it.

4.25 Pacing

Purpose: to match activities to the member's energy, health, time and interest (Session 3).
Steps:
1. Use the pacing worksheet to choose a level for each activity, such as how far to walk.
2. Address all-or-nothing standards along the way.

4.26 Balancing activities

Purpose: to balance responsibilities against time for oneself (Session 3).
Steps:
1. Use the balance-beam picture.
2. Members write a to-do list across the four activity categories.
3. They check whether the list tips too far one way.

4.27 Pleasure predicting

Purpose: to test the depressive prediction that "I won't enjoy it" (Session 3).
Steps:
1. Choose an activity and set up conditions that make enjoyment more likely.
2. Rate expected enjoyment on a 1–5 star scale.
3. Do the activity, then rate actual enjoyment.
4. Compare the two ratings in the group.
The manual notes that actual enjoyment is often higher than predicted.
Practice: one activity from each category, with before and after ratings.

4.28 Activities toward future goals [uncertain: Session 4 named from contents only]

Purpose: to link activities to goals.
Steps ([synthesis]):
1. Each member names a short-term goal and a longer-term goal.
2. They break each goal into weekly activity steps.
3. The group helps check the steps are realistic.

D. People Interactions and Your Mood module

4.29 Chaining (people version)

Purpose: to show how contact, or avoidance of it, moves mood (Session 1, about 20 minutes).
Steps:
1. Put a factual event at 5 on the 1–9 scale.
2. The group brainstorms interactions, or avoidance, that move mood toward 1 and toward 9. The manual's sample runs from cancelling a planned trip at the low end to inviting a friend to dinner at the high end.
3. Members complete the worksheet.

4.30 Social support network map

Purpose: to find gaps and over-reliance on one person (Session 1).
Steps:
1. Members list who gives them practical help, advice, companionship and emotional support.
2. They note whom they support in return.
3. Leaders prompt them to spot gaps and heavy reliance on one person.
4. Each member takes one step toward a stronger network.

4.31 Meeting new people

Purpose: to widen a thin network.
Steps:
1. Start with enjoyable activities done around other people, such as volunteering or joining a club.
2. Build friendships gradually, in public settings.
Watch for: distrust after betrayal. Validate it first, then examine overgeneralised thoughts such as "nobody can be trusted".

4.32 Relationship problem areas: grief, role change, role disagreement

Purpose: to locate where relationships are going wrong (Session 2).
Grief and loss:
- Members write what they are grieving and how it affects their contacts, thoughts and activities.
- Strategies: reach out to supporters, recall the whole life including good memories, use rituals, plan a meaningful activity.
Role change:
- Members list their roles and name their feelings using a feelings list.
- They define the best outcome, then plan steps across interactions, thoughts and behaviour.
Role disagreement:
- The group brainstorms one member's conflict on the board.
- Teach joint problem solving: (1) frame the problem as outside both people; (2) brainstorm; (3) rate each option positive or negative; (4) choose one both people rate positive; (5) try it and revisit.
Each member chooses one problem area as practice.

4.33 Relationship safety screen

Purpose: to detect intimate-partner or family violence (Session 2).
Steps:
1. Members privately answer yes/no questions about fear, hurtful or frightening words and physical aggression.
2. Anyone affected is referred to a leader or counsellor.
Do not discuss answers in the group. [synthesis]

4.34 Counting positive and negative contacts

Purpose: to monitor social contact (from Session 2).
Steps:
1. Members add daily counts of positive and negative contacts to the Quick Mood Scale.
2. Graph one volunteer's counts against mood in review.

4.35 Active listening dyads

Purpose: to practise listening (Session 3, about 20 minutes).
Steps:
1. Members pair up.
2. Each speaks for about five minutes on what kind of person they want to become, while the partner listens without interrupting and then asks follow-up questions.
3. Swap roles.
4. Debrief as a group: how it felt and what helped.

4.36 Communication styles and assertive requests [uncertain: body]

Purpose: to tell passive, aggressive and assertive communication apart, and to practise assertive requests and expressing feelings (Session 3 objectives).
Steps ([synthesis]):
1. Model one request in all three styles.
2. Members script a request of their own.
3. They rehearse it in pairs or in front of the group, then get feedback on content and delivery.

4.37 People module Session 4 [uncertain]

The contents are not given here. Check the guidebook.

E. Exposure-based and process interventions (other protocols)

4.38 Treatment orientation interview (CBGT)

Purpose: an individual meeting before the group starts, a named chapter in Heimberg & Becker.
[uncertain] The contents are not drawn on here.
Steps ([synthesis]):
1. Explain the cognitive-behavioural model of social anxiety.
2. Explain why in-session exposure is central, and what it will ask of the client.
3. Get informed consent to exposure.
4. Start the client's list of feared situations.

4.39 In-session exposure with integrated cognitive restructuring (CBGT core) [uncertain: procedure not drawn on; steps are synthesis]

Purpose: to confront feared social situations in the room while testing the thoughts that come up.
Steps ([synthesis]):
1. Choose a moderately feared situation for one member.
2. Before the exposure, the member names automatic thoughts, labels thinking errors and writes a coping thought.
3. Set an observable goal that does not depend on reducing anxiety.
4. Other members role-play partners or audience.
5. During the exposure, take distress ratings at intervals.
6. Afterwards, review whether the goal was met, what the evidence says about the predictions, and the member's take-away.
7. Link the exposure to homework.
Safety and consent: get consent before each exposure, and tell the member they can pause. Contraindications include acute suicidality, active psychosis and severe substance intoxication. Role-players should not be harsh beyond what was agreed. Debrief the role-players too.

4.40 Process interventions [synthesis; consistent with Bieling et al.'s stated emphasis, specific techniques not drawn on]

Linking: connect one member's thought to others' ("Who else has had a version of that?").
Peer Socratic questioning: invite members to ask the questions rather than give answers.
Here-and-now examples: use interpersonal moments in the group as live cognitive material, such as "they think I'm boring" during a go-round.
End-of-session feedback round: ask each member for one take-away.

5. Handling problems

From the SFGH Leader's Introduction and guidebooks [source: SFGH Introduction; module guidebooks]

A member dominates:
- Interrupt gently, thank them and redirect.
- Make sure everyone speaks at least once.
- The manual's wording begins: "Thank you for sharing your ideas. I wish we had time to hear more..."
Quiet members:
- Invite them by name, or ask the room, "Who haven't we heard from for awhile?"
- If reluctance persists, discuss it with the supervisor, who may arrange individual therapy.
Lateness:
- Talk privately after the session.
- Find the barrier and solve it together.
- Praise them for coming, and say that coming late beats not coming.
Absence:
- Contact the member by phone, in person or with a card, which the group can sign.
- Offer a catch-up and solve practical barriers such as transport or timing.
- If they are discouraged, ask about past efforts that worked and offer a hopeful reframe.
Practice not done:
- Ask about time, reading ability, forgetting and other responsibilities.
- Identify discouraging thoughts such as "nothing will change".
- Do the practice in session, for example the mood scale.
- Stay warm, and remind them attendance still counts.
Crisis (suicidal or violent thoughts, being harmed, harming others): contact the supervisor before the session ends. The supervisor provides emergency numbers and backup contacts. Leaders don't manage it alone.
Conflict between members: discuss it with the supervisor. Removal from the group and referral elsewhere may be needed.
No progress after about four sessions: consult the supervisor about a review or a step-up.
Guilt and perfectionism: point out self-blame and all-or-nothing standards early, and dispute them.
Feeling worse after the group: respond warmly and ask what didn't fit.
Expecting CBT to fix everything: treat it as all-or-nothing thinking.
Distrust after betrayal: validate it, then examine overgeneralisation.
People who already know each other: prevent this at intake. If it happens anyway, watch for guarded participation.

Gaps the sources don't address [synthesis]

Suicide risk in a group:
- Scan the PHQ-9 during the session and ask any member who endorses the suicide item to stay behind.
- Do a standard risk assessment: ideation, intent, plan, history, protective factors.
- Make a safety plan, and do lethal-means counselling about safe storage or removal.
- Document it and inform the supervisor.
- In the group itself, acknowledge disclosures briefly, say that you will follow up, and don't let the group process the details.
Overwhelm or distress in session:
- Lower the demand: pass on that member's turn, or offer a brief grounding pause.
- Check in privately at the break.
- Keep in-session recall of low moments short and move quickly to the worksheet.
- For exposure groups, agree a pause signal in advance and grade tasks down rather than ending the exposure in failure.
Rupture with a leader:
- Name it non-defensively (illustrative: "I may have rushed you just now. How did that land?").
- Take responsibility for your part.
- Offer an individual conversation if group repair feels exposing.
- The co-leader can hold the group while the other repairs.
Subgrouping or scapegoating:
- Restate the norms.
- Spread airtime.
- Address the pattern as a group process, without blaming individuals.
- Consult the supervisor if it continues.
Advice-giving and rescuing: steer members toward questions rather than solutions, using the brainstorm-then-member-chooses format in 4.24.
Mixed severity or comorbidity:
- Screen carefully, since the version followed excludes untreated bipolar disorder and psychosis.
- Offer individual adjuncts to members whose needs exceed the group.
- Avoid having a single "outlier" member, such as the only person with trauma or the only older adult.
Literacy and language: the manual lists reading ability as a practice barrier. Read the material aloud, use visual versions of scales, and use the Spanish participant manual where it fits.
Intoxication: not covered in the 2006 manual. Don't run the session with an intoxicated member. Speak to them privately, check safety and transport, and review at their next contact.
Online groups:
- Before starting, check privacy at both ends and agree emergency contact details and each member's location.
- Set rules about cameras and recording.
- Bieling et al. (2022) cover virtual groups, but that chapter is not drawn on here.
Co-leader disagreements: debrief after every session, settle disagreements outside the room, and take them to supervision.
Dropping out of a closed exposure group: it lowers cohesion and leaves fewer role-players. Name the loss, adjust the role allocations, and consider over-recruiting slightly.

Sources

Sources drawn on:

Group Leader's Introduction: Group CBT for Depression (Miranda et al., rev. 2006)
Thoughts and Your Mood: Group Leader's Guidebook (rev. 2006) (read through part of Session 3)
Activities and Your Mood: Group Leader's Guidebook (rev. 2006) (read to the end of Session 3)
People Interactions and Your Mood: Group Leader's Guidebook (rev. 2006) (read to partway through Session 3)
i4health: Group CBT for Depression manuals page
Guilford: Cognitive-Behavioral Therapy in Groups, 2nd ed. (Bieling, McCabe & Antony)
Guilford: Cognitive-Behavioral Group Therapy for Social Phobia (Heimberg & Becker)
Guilford: CBGT for Social Phobia, contents (print page)